It is well known and widely reported that Aboriginal Australians are
sicker and, on average, die much earlier than non-Aboriginal Australians
(Australian Bureau of Statistics and the Australian Institute of Health
and Welfare 2005; Close the Gap coalition 2008). There have been over
three decades of inquiries, policies, programs and reviews into the health
of Aboriginal Australians (Australian Indigenous Healthinfonet
2010). However, improvements in health outcomes have been limited.

The lack of progress in reducing the gap in health and life expectancy
between Aboriginal and non-Aboriginal Australians points to the need for
all sectors, including the health sector, to examine their structures,
processes, policies and services and to identify and adopt the changes
necessary to improve Aboriginal health outcomes. It is a truism, perhaps,
to point out that one of the major ways that a health system influences
the health of populations is through the implementation of policy ideas.
However, policy ideas evolve and are adapted by the bureaucrats responsible
for their implementation at a variety of levels within organisations and
in communities or populations.

In the Australian health care system Aboriginal people access care through
a variety of services. These services include mainstream, publicly funded
health services that span primary, secondary and tertiary care (primary
health care centres and hospitals), Aboriginal community controlled health
services (which mainly provide primary health care and some specialist
care), and private health care providers such as general practitioners.

In this essay we compare insights from Tess Lea’s ethnography of
a mainstream health service’s workforce with the principles and
practices of the Aboriginal community controlled health sector. This comparison
raises questions about how things might be done differently to improve
Aboriginal health in Australia.

HEALTH PROFESSIONALS AND ABORIGINAL HEALTH

Tess Lea conducted an ethnographic study of the publicly-funded mainstream
Northern Territory health system and its workforce. The research, reported
in Bureaucrats and Bleeding Hearts: Indigenous Health in Northern Australia,
investigated the structures, roles, and methods used by the health workforce
(the ‘bureaucrats’ of the title) to improve the health of
Aboriginal residents of the Northern Territory. Lea’s work stands
in contrast to much current research. She offers a different perspective,
shifting the reader’s gaze away from examining Aboriginal people
and their health, towards criticising the organisation of the mainstream
health care system and the workforce employed to deliver health care and
preventive interventions. Her descriptions of how the health professionals
she calls bureaucrats think and behave sheds light on some reasons why
the mainstream health sector has achieved only limited progress in improving
the health of Aboriginal people and communities in the Northern Territory.

Public health bureaucrats are
a talking and reflective profession.

Lea’s book comprises three parts: a description of the settings
within which bureaucrats work; analysis of how bureaucrats learn and are
socialised to work in these settings; and exploration of how work is carried
out once bureaucrats are fully oriented into the system. The social dynamics
of the bureaucratic setting are introduced using two case studies. The
first describes the process of developing a corporate plan for the health
department. The second describes an elaborate plan to privatise all public
hospitals in the Northern Territory. Through this section we learn how
bureaucrats justify, remember and rewrite history to make it more palatable,
and to make the lost time and effort seem less wasteful. Survival is achieved
by retelling the story in retrospect. The reader also learns why the health
department’s structure and operations require co-ordination, and
that the need for co-ordination is self-perpetuating. The act of co-ordinating
results in greater fragmentation, which, ironically, only more co-ordination
can solve.

Lea’s book reveals that public health bureaucrats are a talking
and reflective profession. Workshops provide the primary platform for
discussion. At first glance it may appear that public health bureaucrats
use workshops as a way of solving problems. But Lea’s ethnography
shows that, in fact, workshops are used, with the help of whiteboards
and dot points, to normalise discussion. Complex discussions are recorded
on the whiteboard as two or three word dot points. These dot points lose
much of the complexity and layers of the discussion, and therefore limit
the ability of the bureaucracy to generate a deeper and more nuanced understanding
of the problem at hand. One of us also noted, reading Lea’s text,
that the dot points tended to gravitate toward themes or ideas we have
heard before. This process limits deeper insight and understanding and
reduces the bureaucracy’s ability to do things differently. Although
one of us enjoyed this part of Lea’s book, the other felt that the
emphasis on the limitations of these discussions obscured an important
prior problem: that underlying all the limitations of the bureaucrats
and their ways of working has been the health sector’s lack of respect
for Aboriginal leadership and direction. Until this is redressed, even
though it might well be possible to have a nuanced discussion that addresses
problems and solutions in more depth, if the wrong people are having the
discussion in the first place, then the quality of that discussion becomes
irrelevant.

Nonetheless, by building on observations and explanations of how agents
of systems learn their roles and behave in practice, Lea’s work
reveals glimpses of the inner voices of bureaucrats at work, engaging
the reader as a first hand witness to ways health bureaucrats learn and
survive in the health system. The book is an important addition to the
literature. The focus on the workforce responsible for the implementation
of public health policy (including health care services and preventive
programs) is innovative and compelling, as is the focus on the organisational
setting within which the workforce is employed.

Describing the problems is no
longer sufficient.

In academic circles Lea’s text has been applauded (Rowse 2009;
Sanders 2009). At the time of this review, no Indigenous perspectives
on the text have been published. Lea’s work certainly helps us to
understand some reasons why it is difficult to close the gaps in life
expectancy and morbidity between Aboriginal and non-Aboriginal Australians.
By describing what bureaucrats working in the mainstream health sector
do and say, she highlights the significance of their roles in determining
the actions taken by the health care system to implement health policy.
This perspective is refreshingly different: rather than focusing on barriers
to organisational change, or the cultural inappropriateness of health
services or departments, Lea observes and explains the reasons for the
actions the bureaucrats take ‘on the job’.

However, although the book offers new understanding of factors contributing
to the slow progress in improving Aboriginal health, it does not move
beyond describing the problem to offer constructive suggestions for change.
It might be argued that this is not the role of an anthropologist or,
alternatively, that better understanding a problem is always a first step
in generating change. However, with the long standing and inequitable
health gap between Aboriginal and other Australians and with the failure
of decades of inquiries and policies to improve Aboriginal health—describing
the problems is no longer sufficient.

We believe that Lea’s book does not pay sufficient attention to
the potential for Western, ill-informed constructions of Indigenous Australians
by health professionals and policy makers to compound the harm and poor
health already present in many Aboriginal communities (Sherwood 2010).
Perhaps this was a deliberate decision on the part of the author. It is
a defensible decision in terms of the conduct of a discrete research project
with limited time and resources. Nonetheless, there is danger that Lea’s
work implies that there is no room for change within the existing bureaucracy—and
that there is no alternative model of policy development and service delivery
to mainstream services to serve Aboriginal people. In fact Aboriginal
community controlled services constitute a significant component of the
health care system for Aboriginal Australians and they provide a clear
alternative with significant advantages.

WHAT LIMITS OUR ABILITY TO DO THINGS DIFFERENTLY?

Notwithstanding our concerns, Lea’s work has provided rare and
valuable insights into the interaction between the ‘system’
in which policy is implemented and the workforce that is actually responsible
for service delivery. Her work builds on that of Michael Lipsky (1980),
who identified street-level bureaucrats—the public service workers
who interact directly with ‘the public’. Many of the practitioners
whose work Lea observed might be viewed as ‘street level bureaucrats’
who mediate the relationship between governments, their agencies and the
public. Lea’s insights also add another dimension to work by Camara
Jones (2000) on racism in health systems. Jones identified three ‘locations’
within which racism is perpetuated—institutions, their agents (often
bureaucrats), and within the people who experience the racism, themselves.

There is danger that Lea’s
work implies that there is no room for change.

Lea has, helpfully, explored ‘from the inside’ the views
and perspectives of the agents—of the people who see, first hand,
the positive and negative, unintended consequences of new policy and who
act to modify it during implementation to make it ‘fit’ their
particular circumstances. However, our own research found that the adaptation
is, most commonly, not a response to community needs or circumstance (nor,
even, to organisational demands). It is determined, principally, by the
pre-existing knowledge and skills of the workforce (Lloyd, Wise &
Weeramanthri 2008). Lea’s research confirms that no matter how well
policy is focused and designed, the likelihood of its being implemented
as intended is heavily influenced by ‘who’ is responsible
for implementation and the organisational structure within which they
are working. This means that the failure of policy makers and academics
to fully understand the reasons for the decisions made by bureaucrats
in the policy implementation process will result in further policy failure
in improving Aboriginal health.

Lipsky’s, Jones’ and our own research confirms that there
is need to do more than develop more effective policy responses to the
health problems defined by Aboriginal communities and/or to develop more
effective health care services and delivery systems. There is also a need,
as Lea has done, to understand better how bureaucrats receive and integrate
new ideas, and how they interact with the systems they work in to mould
the new ideas to fit existing thinking and practices. It is important
to recognise this, because similar policy ideas are shaped and moulded
(and implemented) in very different ways by different systems that have
different workforces, values and priorities (Pressman & Wildavsky
1984; Lloyd 2008).

A REAL ALTERNATIVE: SERVICES UNDER ABORIGINAL CONTROL

In Australia, the clearest point of comparison between systems is between
the mainstream health system and Aboriginal community controlled health
services (ACCHSs). ACCHSs were established in 1971 to address some of
the barriers that had restricted the access of Aboriginal Australians
to quality health care in mainstream Australia—miscommunication
and lack of communication between non-Aboriginal providers and Aboriginal
patients; mistrust of the mainstream health care system by Aboriginal
people; and poor understanding on the part of many non-Aboriginal health
professionals of the impact of their own cultures on the way in which
they provide health care. In effect, ACCHSs are alternative structures
and organisations with different workforces—and exemplify the differences
in the style, type and range of care provided when policies and services
are designed and delivered by organisations that are a practical expression
of Aboriginal self determination in Aboriginal health and health service
delivery (Hunter et al. 2005). The National Aboriginal Health Strategy
Working Party (1989) described the differences in more detail. In short,
the same national and state-wide policy ideas are implemented
differently in the two structures by their two workforces (Larkin,
Geia & Panaretto 2006). Policy, in and of itself, is not sufficient,
on its own, to bring about the changes required to improve the health
of Aboriginal people when the system through which it is to be implemented
is ill-prepared to deliver the policy as intended.

Reading Lea’s work, one can see how little influence the design
and practice of Aboriginal community controlled health services and their
ways of working have had on the ‘mainstream’ health system.
The ACCHSs were developed as an alternative to a mainstream health sector
that manifested all of the challenges Lea identifies. They have provided
vital leadership in defining the characteristics of systems (structures,
processes, and the workforce) that more precisely meet the health needs
of Aboriginal people and communities. There is evidence of the effectiveness
of organisations that are under Aboriginal leadership and that have responsibility
for employing their workforces, for developing new policies, for allocating
resources, and for designing and delivering interventions and services
(Sherwood 2010; Chandler & Lalonde 1997; Dodson & Sanders 2003).
For example, there is a greater number of Aboriginal health workers employed
in ACCHSs than in mainstream health services. Research shows that having
more Aboriginal health workers involved in primary health care influences
the nature of consultations, the time spent with patients, the number
of problems that are managed, and the emphasis on public health (Larkin,
Geia & Panaretto 2006).

New policy ideas are shaped by
the systems and agents that implement them.

Despite this evidence, it has proven difficult for governments, which
have jurisdictional authority over the provision of health services and
are responsible for their funding, to ensure that both mainstream health
services and the ACCHSs each make optimal contributions to improving Aboriginal
health. The Overburden Report (Dwyer et al. 2009) recommended one way
to increase the effectiveness of ACCHSs and of mainstream health services
in providing the range and quality of care required to reduce the gap
in mortality and morbidity between Aboriginal and non-Aboriginal Australians.
That review proposed that ‘relational’ or ‘alliance’
contracting, rather than complex and fragmented contracts, would offer
a way of improving accountability mechanisms and relationships between
health authorities and ACCHSs (Dwyer et al. 2009). Alliance contracting
is characterised by collective sharing of responsibilities and risks,
under funding arrangements that are transparent without being overly bureaucratic.
We support Dwyer’s recommendation for alliance contracting because
we believe it is an example of one feasible, practical change that might
better support and nurture the relationship between the government and
ACCHSs.

Lea’s work illustrates how new policy ideas, no matter how relevant
and evidence-based, evolve and are shaped by the systems and agents that
are required to implement them (Lloyd 2008). The implication is that the
failure to fully understand (and modify) how bureaucrats adapt policy
at the point of implementation will lead to further failures to improve
Aboriginal health. It is by understanding (and influencing) how health
professionals shape and are shaped by the systems within which they have
been educated, trained, and employed that it will be possible to develop
more effective ways of working.

The history of colonisation and of government control over Aboriginal
people has been institutionalised in the policies and practices of organisations
and within the world views, education and training of health professionals
(Jones 2000). Several changes are necessary to redress the problems that
Lea’s research points to, including critical reflection on the membership,
roles and work of the health bureaucracy in improving Aboriginal health;
attitudinal change among non-Aboriginal Australians; and leadership and
determination to do things differently. Most importantly, in 2011, in
Australia, there remains a need for recognition and agreement that Aboriginal
people need to have the authority to manage their own affairs—including,
but not limited to, health services (Lavoie et al. 2010).

REFERENCES

Australian Bureau of Statistics and the Australian Institute of Health
and Welfare 2005, ‘The Health and Welfare of Australia’s
Aboriginal and Torres Strait Islander Peoples’, Commonwealth
of Australia, Canberra.

Sherwood, J. 2010, Do No Harm: Decolonising Aboriginal Health Research,
PhD thesis, University of New South Wales, Sydney.

POSTSCRIPT

We are disappointed that, in our search for responses and reviews to
Lea’'s text, we missed an important and insightful review by Professor
Ian Anderson of the University of Melbourne. It can be found online at:
http://inside.org.au/bureaucracys-bleeding-northern-heart/.
(J.L. and M.W., 7 March 2011)

Dr Jane Lloyd is a Research Fellow at the
Indigenous Policy and Dialogue Research Unit at the University of New
South Wales. Jane is currently working on an Australian Research Council
Linkage Grant investigating the use of evidence in Indigenous policy.

Marilyn Wise is Associate Professor of Healthy
Public Policy at the Centre for Health Equity Training Research and Evaluation
(CHETRE), which is part of the UNSW Research Centre for Primary Health
Care and Equity. She was one of the authors of the Health Impact Assessment
of the Northern Territory Emergency Response conducted by the Australian
Indigenous Doctors’ Association and CHETRE in 2008–09.